Pre-op: CTA/MRA or lower extremity angiogram to confirm 3-vessel runoff to the foot.

Bone Harvest: Lateral aspect of lower leg. Up to 25cm of bone available. Crucial rule: Must preserve 6-8 cm of distal fibula (ankle stability) and proximal fibula (knee stability/fibular nerve).

Skin Paddle: Designed over the posterolateral intermuscular septum. Relies on septocutaneous perforators (usually lower 1/3 to middle 1/3 of leg).

Included Muscle(s): A 1-2 cm cuff of the Flexor Hallucis Longus (FHL) and Tibialis Posterior is typically retained along the posterior/medial aspect of the bone to protect the peroneal vessels. A larger segment of the Soleus or FHL can be included if extra soft-tissue bulk is required.

Modification: Can be osteotomized multiple times (closing wedges) to perfectly mimic the mandibular curve.

Pre-op: Allen's test is absolutely mandatory to ensure ulnar artery collateral perfusion to the hand.

Harvest: Volar aspect of the non-dominant forearm. Designed over the course of the radial artery between the brachioradialis and flexor carpi radialis (FCR).

Dissection: Subfascial plane, ensuring paratenon over flexor tendons is preserved to allow for split-thickness skin graft (STSG) take.

Included Muscle(s): None (Strictly fasciocutaneous). The flap is elevated off the underlying Brachioradialis and Flexor Carpi Radialis muscles, which are preserved in the donor bed.

Same soft tissue design as RFFF. Include a segment of the radius along the intermuscular septum.

Included Muscle(s): None (Minimal). Only a very small cuff of the Flexor Pollicis Longus (FPL) and Pronator Quadratus muscular attachments are retained specifically to preserve the periosteal blood supply to the harvested bone segment.

Critical Constraint:

Bone harvest is limited to a maximum of 10-12 cm in length and strictly no more than 40% of the cross-sectional circumference of the radius.

Post-op: Prophylactic plating of the radius (keel shape cut preferred) and prolonged immobilization are often required to prevent pathological fracture.

Bone Harvest: Taken from the anterior ilium starting ~2cm posterior to the Anterior Superior Iliac Spine (ASIS). Can be harvested as an inner table block or a full-thickness bicortical segment.

Included Muscle(s): The Internal Oblique muscle is frequently co-harvested (based on the ascending branch of the DCIA) to provide bulky, reliable, mucosalized soft tissue coverage for the oral cavity. A small cuff of Transversus Abdominis and External Oblique is retained over the inner crest to protect the pedicle.

Donor Site Note: High morbidity risk. Requires meticulous multilayer abdominal wall closure to prevent hernia formation. Patients may experience temporary lateral femoral cutaneous nerve neuropraxia and gait disturbances.

Design: Axis is a line drawn from ASIS to superolateral patella. Perforators usually found within a 3cm radius of the midpoint of this line.

Harvest: Subfascial or suprafascial dissection. Identifying and tracing perforators through the vastus lateralis muscle requires meticulous microsurgical technique.

Included Muscle(s): Variable. Can be harvested as a pure fasciocutaneous flap (no muscle) by meticulously dissecting perforators free, or as a myocutaneous/chimeric flap including a portion or the entirety of the Vastus Lateralis muscle for dead space obliteration.

Versatility: Can be thinned primarily (microdissection of subcutaneous fat) or harvested as a chimeric flap (skin paddle + separate vastus lateralis muscle block on same pedicle for dead space obliteration).

Donor site generally closed primarily if width is < 8-10 cm.

Design: The flap is centered over the lateral intermuscular septum of the arm. The axis is a line drawn from the deltoid insertion down to the lateral epicondyle of the humerus.

Included Muscle(s): None (Strictly fasciocutaneous). The flap is elevated off the triceps posteriorly and the brachialis/brachioradialis anteriorly. A very thin rim of triceps fascia is sometimes preserved around the septum to protect the perforating vessels.

Donor Site: Widths up to 6-8 cm can usually be closed primarily. If primary closure is achieved, the resulting linear scar is easily hidden beneath short sleeves.

Design: Skin paddle drawn inferomedially to the nipple/areola complex (to capture random musculocutaneous perforators). Muscle is released from humeral, clavicular, and sternal attachments.

Included Muscle(s): Pectoralis Major. The muscle itself acts as the vascular carrier for the overlying skin paddle and provides significant bulk to cover neurovascular structures in the neck.

Arc of Rotation: Rotated up to 180 degrees into the neck/face over the clavicle. Clavicle can act as a fulcrum and compress the pedicle; occasionally a portion of clavicle is removed or the flap is tunneled beneath it.

Drawbacks: Bulky (especially in women with breast tissue), creates neck tethering, significant chest wall deformity, gravity pulls flap down over time.

Design: Extremely large skin paddles (e.g., 10x20 cm) can be harvested safely. Can also harvest muscle alone and cover with STSG.

Harvest (Pedicled): Muscle detached from spine/iliac crest. Pedicle isolated in the axilla. Flap is tunneled through the axilla to the neck.

Included Muscle(s): Latissimus Dorsi. Often harvested as a large myocutaneous flap or a muscle-only flap. (The Serratus Anterior muscle can occasionally be co-harvested based on the subscapular system for chimeric needs).

Level I: Submental (Ia) and Submandibular (Ib). Bounded by the anterior/posterior bellies of the digastric muscle and the mandible.

Level II: Upper Jugular. Skull base down to the carotid bifurcation (clinical landmark: hyoid bone). Anterior to posterior border of SCM.

Level III: Middle Jugular. Carotid bifurcation down to the omohyoid muscle (clinical landmark: cricoid cartilage).

Level IV: Lower Jugular. Omohyoid muscle down to the clavicle.

Level V: Posterior Triangle. Posterior boundary of SCM to anterior boundary of trapezius.

Level VI: Anterior Compartment. Hyoid bone to suprasternal notch, bounded laterally by medial borders of carotid sheaths.